Details

Autor(en) / Beteiligte

• Vishwanath, Soumya

Titel

Evaluating proactive outreach for prior authorization recertifications in Medicaid patients

Ist Teil von

• The American journal of managed care, 2021-11, Vol.27 (11), p.e395-e399

Ort / Verlag

Jamesburg: MultiMedia Healthcare Inc

Erscheinungsjahr

2021

Quelle

EZB Electronic Journals Library

Beschreibungen/Notizen

• Am J Manag Care. 2021;27(11):e395-e399. https://doi.org/10.37765/ajmc.2021.88783 _____ Takeaway Points Implementing a proactive outreach program for prior authorization (PA) recertifications in a state Medicaid population resulted in significantly more PA submissions and a reduction in time to PA submission, increasing patient access to medications. * Studies have examined challenges (eg, monitoring PA status) among providers and patients that affect PA delays and continuity of care; however, limited literature exists on effective proactive interventions in the PA process. * This study provides information for payers that can guide the development of clinical outreach programs that monitor adherence and outcomes, reduce provider administrative tasks (eg, tracking PA duration), and ensure that medications are available for patients. * Further studies could examine proactive PA interventions for additional at-risk populations and may directly compare various forms of outreach (eg, mail, telephone, fax, email), frequency (eg, weekly, twice weekly), and the intervention's impact on total medical expenses (eg, hospitalizations, emergency department visits). _____ Continuity of care results from ongoing health care management facilitated by an interdisciplinary team of various health care providers (eg, physicians, nurses, pharmacists) with a shared goal of high-quality, cost-effective medical care. The goal is to reduce fragmentation of care and improve patient safety and quality of care.1,2 Pharmacists play a vital role in the team-based approach necessary to strengthen continuity of care.3 The American Society of Health-System Pharmacists recognizes continuity of care as a vital requirement in the appropriate use of medications and encourages pharmacists to ensure the continuity of pharmaceutical care as patients transition between settings (eg, hospital to community, provider to provider, outpatient visit to home).3 One way in which continuity of pharmaceutical care may be fragmented is through delays in the prior authorization (PA) process, specifically if a patient does not have an active PA or one is not submitted to extend an existing authorization.4 PA is a formulary management strategy used to assess medical necessity of the requested medication and to encourage the use of effective and less costly therapies.3 PA requests are submitted by prescribers (eg, physicians, nurse practitioners) for specific medications (eg, high-cost specialty medications, medications requiring extra monitoring for safety) and receive approval from the health plan prior to the medication being covered.4 The duration of PA approvals varies based upon the medication requested, the clinical rationale for use, and the health plan. Medication nonadherence is defined as any deviation from the prescribed course of medical treatment and is vital in predicting patient outcomes.5 Medication nonadherence varies by disease, patient characteristics, and insurance coverage.6 Poor medication adherence often leads to preventable worsening of disease, additional health risks (eg, adverse events), and increased medical costs (eg, hospitalizations, emergency department [ED] visits).5 Approximately 10% of hospitalizations in older adults are attributed to medication nonadherence, with costs for all-cause (ie, not disease specific) nonadherence ranging between $5271 and $52,341.6 There are multiple risk factors for poor medication adherence, including the patient's inability to access or renew prescriptions, failure to take the medicine as prescribed, and abandonment of the medication regimen altogether.5 Having an active PA on file helps ensure that barriers such as inability to renew prescriptions and abandonment of medication regimen are reduced. METHODS Population PAs for Massachusetts Medicaid (MassHealth) patients in the fee-for-service (FFS), primary care clinician (PCC), and primary care accountable care organization (ACO-B) plans who were enrolled in the Community Case Management (CCM) program were analyzed.